MEDICARE: LAWRENCE STEWART OLSEN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	102121-2501	UT

General Provider Information

NPI Number	:	1972724110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWRENCE STEWART OLSEN PH.D.

Provider Business Mailing Address
First Line	:	2005 E 2700 S STE 180
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1759
Country	:	US
Telephone Number	:	801-230-6508
Fax Number	:	801-322-3890

Provider Business Practice Location Address
First Line	:	2005 E 2700 S STE 180
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1759
Country	:	US
Telephone Number	:	801-230-6508
Fax Number	:	801-322-3890

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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